What is the recommended treatment for pneumonia?

Treatment for Pneumonia

The recommended first-line treatment for community-acquired pneumonia (CAP) is a β-lactam (such as amoxicillin, amoxicillin-clavulanate, or ceftriaxone) plus a macrolide (such as azithromycin) to ensure adequate coverage of both typical and atypical pathogens while reducing mortality. 1

Treatment Algorithm Based on Severity and Setting

Outpatient Treatment (Non-Severe CAP)

• First choice: Oral amoxicillin 500-1000 mg three times daily for 5-7 days 1
  • For patients with comorbidities: Add azithromycin 500 mg on day 1, followed by 250 mg once daily for days 2-5 2
• Alternatives for penicillin allergy:
  • Doxycycline 100 mg twice daily for 5-7 days 1
  • Moxifloxacin or levofloxacin (respiratory fluoroquinolones) 3
    • Levofloxacin: 750 mg once daily for 5 days or 500 mg once daily for 7-10 days 4, 5

Hospitalized Patients (Non-ICU)

• First choice: Intravenous β-lactam (ceftriaxone, cefotaxime, or ampicillin-sulbactam) plus a macrolide 3, 1
  • Ceftriaxone: 1-2 g IV daily
  • Azithromycin: 500 mg IV/PO daily
• Alternative: Respiratory fluoroquinolone monotherapy (levofloxacin 750 mg daily or moxifloxacin) 3
• Duration: Minimum 5 days, ensuring the patient is afebrile for 48-72 hours and has no more than 1 CAP-associated sign of clinical instability before discontinuing therapy 3

Severe CAP (ICU Patients)

• No risk for Pseudomonas aeruginosa:
  • Non-antipseudomonal cephalosporin III (ceftriaxone) + macrolide
  • OR moxifloxacin or levofloxacin ± non-antipseudomonal cephalosporin III 3
• Risk factors for P. aeruginosa:
  • Antipseudomonal cephalosporin (cefepime/ceftazidime) or piperacillin-tazobactam or carbapenem (meropenem preferred)
  • PLUS either ciprofloxacin OR macrolide + aminoglycoside (gentamicin, tobramycin, or amikacin) 3, 1

Special Considerations

Aspiration Pneumonia

• Hospital ward, admitted from home:
  • β-lactam/β-lactamase inhibitor (amoxicillin-clavulanate)
  • OR clindamycin
  • OR cephalosporin + metronidazole
  • OR moxifloxacin 3
• ICU or admitted from nursing home:
  • Clindamycin + cephalosporin 3

MRSA Coverage

• Add vancomycin or linezolid if community-acquired MRSA is suspected 3

Switch from IV to Oral Therapy

• Consider switching to oral therapy when:
  • Patient is hemodynamically stable and clinically improving
  • Patient can tolerate oral medications
  • Patient has a normally functioning gastrointestinal tract 3
• Most patients don't need to remain hospitalized after switching to oral therapy 3

Duration of Treatment

• Standard duration: 5-7 days for most patients with CAP 1, 6
• Minimum duration: 5 days, ensuring the patient is afebrile for 48-72 hours 3
• Extended therapy (14-21 days) may be needed for:
  • Legionella pneumonia
  • Staphylococcal pneumonia
  • Gram-negative enteric bacilli pneumonia 3

Monitoring Response to Treatment

• Assess clinical response within 48-72 hours using:
  • Temperature
  • Respiratory rate
  • Oxygen saturation
  • Other vital signs 1
• Consider measuring C-reactive protein on days 1 and 3-4 to assess response, especially in patients with unfavorable clinical parameters 3

Management of Non-Responding Pneumonia

If a patient fails to improve after 48-72 hours:

1. Review clinical history, examination, and all investigation results
2. Consider additional diagnostic testing
3. Consider changing antibiotics:
   • For non-severe pneumonia on amoxicillin monotherapy: Add or substitute a macrolide
   • For non-severe pneumonia on combination therapy: Consider switching to a respiratory fluoroquinolone 3, 1

Common Pitfalls to Avoid

1. Delaying appropriate broad-spectrum coverage in severe cases - initial empiric therapy should be broad with appropriate de-escalation once culture results are available 1
2. Not considering local resistance patterns when choosing initial therapy 1
3. Failing to adjust therapy based on recent antibiotic exposure - use an alternative class if the patient received antibiotics within the past 90 days 1
4. Prolonged IV therapy when oral therapy would be appropriate - switch to oral treatment after reaching clinical stability 3
5. Inappropriate use of steroids - steroids are not recommended in routine treatment of pneumonia 3

By following this evidence-based approach to pneumonia treatment, clinicians can optimize patient outcomes while minimizing the risk of antibiotic resistance and adverse effects.